National Disease Surveillance Program - II. Disease Summaries

Forms and Documents

Document Name	Status
0920-0004 Influenza Annual Survey 55.31A Form	Modified
Antiviral-Resistant Influenza Infection Case Report Form Form	New
CMRS Weekly - City Health Officer or Vital Statistics Registrars Form	Modified
CMRS Daily - City Health Officer or Vital Statistics Registrars Form	Modified
Daily Influenza-like Illness year round Form	Modified
Daily Influenza-like Illness Oct - May Form	Modified
Form 55.20 Weekly Influenza-like Illiness year round 55.20 Form	Modified
Form 55.20 Weekly Influenza-like Illness Oct - May 55.20 Form	Modified
Influenza Associated Pediatric Death Case Report Form Form	Modified
Influenza virus Internet Year-Round 55.31 Form	Modified
Influenza virus Internet Oct - May 55.31 Form	Modified
Influenza virus fax year-round 55.31 Form	Modified
Form Influenza Fax Influenza Virus Fax Oct-May 55.31 Form	Modified
Aggregate Hospitalization and Death Reporting Weekly Form	Modified
Possible Human Rabies - Patient Information Form Form	Modified
Novel Human Influenza A Virus Infection Case Report Form Form	Modified
Novel and Pandemic Influenza A Virus Infection Contact Trace Forward Form Form	Modified
Novel and Pandemic Influenza A Virus Infection Contact Trace Back Form Form	Modified
Novel and Pandemic Influenza A Virus Infection Case Investigation Form Form	Modified
Daily Novel and Pandemic Influenza Virus State Case Status Summary Update Form	Modified
Brucellosis Case Report Form Form	Modified
Babesiosis Case Report Form Form and Instruction	Modified
Form No Number HABISS Monthly Reporting Form Form	Modified
Form No number HABISS Form	Modified
Form CDC.52.12 0920-0004 Waterborne Diseases Outbreak 52.12 Form	Modified
Form 55.28 Enhanced Animal Rabies Surveillance Monthly Report Form	Modified
Form 52.13 0920-0004 Foodborne Outbreak 52.13 Form and Instruction	Modified
0920-0004 Arboviral Diseases Form and Instruction	Modified
Form 1 0920-0004 Diarrheal Diseases Campylobacter Form	Modified
Change Request OMB 0920-0004 4-5-13.docx Justification for No Material/Nonsubstantive Change	2013-04-05
PHIN cover sheet.docx Supplementary Document	2010-11-02
PHLIP cover sheet.docx Supplementary Document	2010-11-02
Enhanced Animal Rabies Surveillance cover sheet.docx Supplementary Document	2010-10-29
NORS Form.pdf Supplementary Document	2008-12-22
FoodborneOutbreak Form 5213 ReportingInstructions.pdf Supplementary Document	2007-01-17
NREVSS PCR Worksheet CDC 55.83D.pdf Supplementary Document	2007-01-17
NREVSS VI Worksheet CDC 55.83B.pdf Supplementary Document	2007-01-17
NREVSS EM Worksheet CDC 55.83C.pdf Supplementary Document	2007-01-17

IC Document Collections

IC ID	Document Title	Status
37707	0920-0004 Influenza Annual Survey 55.31A Form	Modified
206418	Antiviral-Resistant Influenza Infection Case Report Form Form	New
199058	CMRS Weekly - City Health Officer or Vital Statistics Registrars Form	Modified
199057	CMRS Daily - City Health Officer or Vital Statistics Registrars Form	Modified
199056	Daily Influenza-like Illness year round Form	Modified
199055	Daily Influenza-like Illness Oct - May Form	Modified
199054	Weekly Influenza-like Illiness year round 55.20 Form	Modified
199053	Weekly Influenza-like Illness Oct - May 55.20 Form	Modified
199052	Influenza Virus Electronic year round PHIN-MS Other-Variables for Reporting	Modified
199051	Influenza Virus Electronic year round - PHLIP Other-Variables for electronic reporting	Modified
199050	Influenza Associated Pediatric Death Case Report Form Form	Modified
199049	Influenza virus Internet Year-Round 55.31 Form	Modified
199048	Influenza virus Internet Oct - May 55.31 Form	Modified
199047	Influenza virus fax year-round 55.31 Form	Modified
199046	Influenza Virus Fax Oct-May 55.31 Form	Modified
199045	Aggregate Hospitalization and Death Reporting Weekly Form	Modified
199044	Possible Human Rabies - Patient Information Form Form	Modified
199043	Novel Human Influenza A Virus Infection Case Report Form Form	Modified
199042	Novel and Pandemic Influenza A Virus Infection Contact Trace Forward Form Form	Modified
199041	Novel and Pandemic Influenza A Virus Infection Contact Trace Back Form Form	Modified
199040	Novel and Pandemic Influenza A Virus Infection Case Investigation Form Form	Modified
199039	Daily Novel and Pandemic Influenza Virus State Case Status Summary Update Form	Modified
199038	Brucellosis Case Report Form Form	Modified
199037	Babesiosis Case Report Form Form and Instruction	Modified
186749	HABISS Monthly Reporting Form Form	Modified
186748	HABISS Form	Modified
178375	0920-0004 Listeria Case Form Instruction	Modified
178374	0920-0004 Suspected Viral Gastroenteritis (AKA Calicivirus Surveillance) Instruction	Modified
178373	0920-0004 Cholera and Other Vibrio Illnesses 52.79 Instruction	Modified
178372	0920-0004 Waterborne Diseases Outbreak 52.12 Form	Modified
178371	Enhanced Animal Rabies Surveillance Monthly Report Form	Modified
178370	Rabies Monthly Report (paper) 55.28 Instruction	Modified
178369	0920-0004 Foodborne Outbreak 52.13 Form and Instruction	Modified
178365	0920-0004 National Respiratory and Enteric Virus Surveillance System NREVSS 55.83A-D Instruction	Modified
178364	0920-0004 National Enterovirus Surveillance Report 55.9 Instruction	Modified
178363	0920-0004 Arboviral Diseases Form and Instruction	Modified
178362	0920-0004 Diarrheal Diseases Shigella Instruction	Modified
178361	0920-0004 Diarrheal Diseases Salmonella Instruction	Modified
178360	0920-0004 Diarrheal Diseases Campylobacter Form	Modified

ICR Details

OMB Control No: 0920-0004	ICR Reference No: 201304-0920-006
Status: Historical Inactive	Previous ICR Reference No: 201108-0920-011
Agency/Subagency: HHS/CDC	Agency Tracking No: 19232
Title: National Disease Surveillance Program - II. Disease Summaries
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Improperly submitted and continue	Conclusion Date: 04/10/2013
	Date Received in OIRA: 04/09/2013
Terms of Clearance: Please ensure that a burden statement is included in the submission and that the abstract matches the request.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2014	08/31/2014	08/31/2014
Responses	292,485	0	292,485
Time Burden (Hours)	56,136	0	56,136
Cost Burden (Dollars)	0	0	0

---

Abstract: Data on disease and preventable conditions are collected in accordance with jointly approved plans by the Center for Disease Control and Prevention and the Council of State and Territorial Health Epidemiologists. This revision request entails new disease forms being added and edits to existing forms.

---

Authorizing Statute(s): US Code: 42 USC 241 Name of Law: Public Health Service Act
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 39

IC Title	Form No.	Form Name
0920-0004 Influenza Annual Survey 55.31A	none	Influenza Annual Survey
0920-0004 Diarrheal Diseases Campylobacter	1	Diarrheal Disease Surveillance Campylobacter
0920-0004 Diarrheal Diseases Salmonella
0920-0004 Diarrheal Diseases Shigella
0920-0004 Arboviral Diseases	none	Arboviral Diseases
0920-0004 National Enterovirus Surveillance Report 55.9
0920-0004 National Respiratory and Enteric Virus Surveillance System NREVSS 55.83A-D
0920-0004 Foodborne Outbreak 52.13	52.13	National Outbreak Reporting System: Foodborne Disease Transmission, Person-to-Person Disease Transmission, Animal Contact
Rabies Monthly Report (paper) 55.28
Enhanced Animal Rabies Surveillance Monthly Report	55.28	Lab confirmed cases of rabies
0920-0004 Waterborne Diseases Outbreak 52.12	CDC.52.12	National Outbreak Reporting System: Waterborne Disease Transmission
0920-0004 Cholera and Other Vibrio Illnesses 52.79
0920-0004 Suspected Viral Gastroenteritis (AKA Calicivirus Surveillance)
0920-0004 Listeria Case Form
HABISS	No number	HABISS
HABISS Monthly Reporting Form	No Number	HABISS Report
Babesiosis Case Report Form	none	Babesiosis Case Report Form
Brucellosis Case Report Form	none	Brucellosis Case Report Form
Daily Novel and Pandemic Influenza Virus State Case Status Summary Update	none	Daily Case Status
Novel and Pandemic Influenza A Virus Infection Case Investigation Form	none	Influenza A Case Investigation
Novel and Pandemic Influenza A Virus Infection Contact Trace Back Form	none	Influenza A Trace Back
Novel and Pandemic Influenza A Virus Infection Contact Trace Forward Form	none	Trace Forward
Novel Human Influenza A Virus Infection Case Report Form	none	Novel Human Influenza A Case
Possible Human Rabies - Patient Information Form	none	Possible Human Rabies
Aggregate Hospitalization and Death Reporting Weekly	none	Aggregate Hospital
Influenza Virus Fax Oct-May 55.31	Influenza Fax	WHO Fax Form
Influenza virus fax year-round 55.31	none	WHO Fax Form
Influenza virus Internet Oct - May 55.31	none	WHO Electronic
Influenza virus Internet Year-Round 55.31	none	WHO Electronic Form
Influenza Associated Pediatric Death Case Report Form	none	Pediatric Death Case Report
Influenza Virus Electronic year round - PHLIP
Influenza Virus Electronic year round PHIN-MS
Weekly Influenza-like Illness Oct - May 55.20	55.20	Weekly Influenza-like Illness
Weekly Influenza-like Illiness year round 55.20	55.20	Weekly Influenza Like Illness
Daily Influenza-like Illness Oct - May	none	Influenza-like Illness Daily and year round
Daily Influenza-like Illness year round	none	Influenza-like illness Reporting
CMRS Daily - City Health Officer or Vital Statistics Registrars	none	CMRS Daily
CMRS Weekly - City Health Officer or Vital Statistics Registrars	none	CMRS Weekly
Antiviral-Resistant Influenza Infection Case Report Form	None	Antiviral-Resistant Influenza Infection Case Report Form

---

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

---

Annual Cost to Federal Government: $40,000

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  No

---

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 04/09/2013

---